Provider Demographics
NPI:1407810633
Name:BERTOGLIO, MARK RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RAYMOND
Last Name:BERTOGLIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 OLIVE HWY
Mailing Address - Street 2:STE 12
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966
Mailing Address - Country:US
Mailing Address - Phone:530-533-6061
Mailing Address - Fax:530-533-4438
Practice Address - Street 1:2721 OLIVE HWY
Practice Address - Street 2:STE 12
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966
Practice Address - Country:US
Practice Address - Phone:530-533-6061
Practice Address - Fax:530-533-4438
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG34557207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG34557OtherSTATE LICENSE
CAGR0014101Medicaid
CAGR0014101Medicaid
CAGR0014101Medicaid
AB9765819OtherDEA